10/4/2016. The effect of point-of-sale tobacco marketing on smoking cessation. Background. Background

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1 The effect of point-of-sale tobacco marketing on smoking cessation M Siahpush, R Shaikh, D Smith, A Hyland, K M Cummings, A Sikora Kessler, M D Dodd, L Carlson, A Ramos, A Correa, J Meza, M Wakefield Research reported in this publication was supported by NIH grant R01CA and FDA Center for Tobacco Products (CTP). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the Food and Drug Administration. Background There is ample evidence to suggest that population-level tobacco control policies such as increasing the price of tobacco products, restricting smoking in public places, and anti-smoking mass media campaigns promote smoking cessation. However, little is known about how tobacco marketing regulation affects smoking cessation. Traditional electronic, billboard, and print forms of tobacco marketing are restricted, and the tobacco industry has relied increasingly on point-of-sale (POS) marketing (i.e., marketing at retail stores where tobacco is sold). In fact, the tobacco industry allocates the largest proportion of its $12.5 billion marketing campaign to POS marketing each year (or $35 million a day). Background POS tobacco marketing is: carefully crafted, creatively executed, well-financed, well-researched promotional efforts supervised by [tobacco industry s] senior management. Tobacco companies provide retailers with financial incentives to secure their cooperation in the following three major marketing areas: 1) providing POS product displays 2) posting POS advertising 3) offering promotional and price incentives to consumers. 1

2 Cigarette Pack Displays Images Courtesy: 10 Advertising Images Courtesy: Promotional and Price Incentives Images Courtesy: 2

3 Aim 1 POS marketing and craving to smoke Cigarette marketing may act as a cue to smoke and prompt craving to smoke. Laboratory studies show exposure to cigarette imagery promotes craving to smoke (Pynter et al. 2009). These studies have focused on one type of cigarette POS marketing, namely cigarette pack displays. The effect of cigarette advertisements and promotions on cravings have never been addressed. Furthermore, there are no real world studies about POS cigarette marketing and cravings to smoke. Aim 1: To assess the association of a scale of POS cigarette marketing and cravings to smoke. Aim 2 POS marketing, urge to buy and unplanned purchase of cigarettes The main aim of POS tobacco marketing is to influence purchasing behavior. This can occur by stimulating an urge to buy and an impulse (unplanned) purchase of cigarettes. A study in Australia, found over one third of smokers interviewed indicated that seeing pack displays gives them an urge to buy cigarettes. About one quarter of smokers at least sometimes decided to buy cigarettes as a result of seeing pack displays. (Wakefield et al. 2008) The existing studies only focus on pack displays and do not consider advertisement and promotion. Aim 2: To assess the association of a scale of POS marketing with urge to buy cigarettes and unplanned purchase of cigarettes. Aim 3 POS marketing and quitting Germain et al. (2009) examined the effect of sensitivity to POS tobacco displays on quitting behavior. Sensitivity to POS tobacco displays was measured with an index consisting of the following three variables: (1) the frequency of noticing tobacco displays, (2) unplanned purchasing behavior, and (3) deciding on brands based on POS displays. The results revealed that lower sensitivity to POS marketing was associated with a higher probably of smoking cessation. In a qualitative study in New Zealand, Hoek et al. (2010) found that tobacco displays elicited emotional and physical reactions that undermined quit attempts. These studies only focused on a single aspect of POS tobacco marketing, namely product displays. There are no other studies that address how POS marketing influences smoking cessation. Aim 3. To employ a scale of POS tobacco marketing and examine its prospective association with quit attempt and quit success. 3

4 Conceptual model for the effect of point-of-sale (POS) tobacco marketing on quit attempt and quit success Measured at baseline Measured at six-month follow-up Craving to smoke Urge to buy cigarettes POS tobacco marketing Unplanned purchase of cigarettes Quit attempt Quit success Aim 4 POS marketing and smoking-induced deprivation Research shows that spending money on cigarettes and smoking can diminish financial and material well-being, and create financial stress (Siahpush et al., 2013, 2012, 2004, 2003). Research also shows that smoking can lead to smoking-induced deprivation (SID), i.e., whether spending money on cigarettes results in not having enough money for essentials such as food.(siahpush et al., 2013, 2012) An unexplored area of research is the extent to which POS marketing and its immediate consequences such as stimulating cravings to smoke, urges to buy cigarettes, and unplanned purchases of cigarettes, can contribute to the deleterious effects of smoking on the standards of living of smokers and specifically on SID. 11 Aim 4 POS marketing and smoking-induced deprivation Aim 4. to use structural equation modelling to examine the relationship between POS cigarette marketing and SID and investigate how this relationship is mediated by cravings to smoke, urges to buy cigarettes, and unplanned purchases of cigarettes. Cravings Point of Sale Marketing Smoking Induced Deprivation Urges to Buy Unplanned Purchases 4

5 Prospective design. A 30-minute baseline (n=999) and a 10- minute six-month follow-up telephone interview. Random digit dialing and placement of local advertisements. The baseline interview collected data on: noticing POS marketing, craving to smoke, urge to buy cigarettes, unplanned purchase of cigarettes, SID sociodemographic and other covariates. Quit attempt and quit success assessed during the sixmonth follow-up interviews, with attrition rate of 32%. Measurement of POS marketing: Baseline survey asked the following questions: (1) When you are in a store in your neighborhood, how often do you notice tobacco ads? (2) When you are in a store in your neighborhood, how often do you notice tobacco promotions such as special prices, multi-pack discounts, or free gift with purchase of cigarettes? (3) When you are in a store in your neighborhood, how often do you notice cigarette pack displays? Possible responses to each question were: 1 = never, 2 = rarely, 3 = sometimes, 4 = often, 5 = always. The responses to the three questions were summed to create a scale of exposure to POS tobacco marketing with scores ranging from 3 (low marketing) to 15 (high marketing). (Cronbach s alpha = 0.64). Aim 1: To assess the association of a scale of POS cigarette marketing and cravings to smoke. Measurement of craving to smoke: When you are in a store in your neighborhood that sells tobacco products, how often do you:(lochbuehler K, et al. 2009; Perkins KA et al., 2004; Conklin CA et al., 2008; Warthen MW et al., 2009) (1) feel a craving for a cigarette? (2) feel like nothing would be better than smoking a cigarette? (3) feel like all you want is a cigarette? 1 = never, 2 = rarely, 3 = sometimes, 4 = often, 5 = always. We summed responses to these questions to create a scale with a range of scores from 3 to 15, with higher scores representing a higher level of craving to smoke (Cronbach s alpha = 0.77). 5

6 Aim 2: To assess the association of a scale of POS marketing with urge to buy cigarettes and unplanned purchase of cigarettes. Measurement of urge to buy cigarettes and unplanned purchase of cigarettes: When you are in a store in your neighborhood, how often do you get an urge to buy cigarettes? When you are in a store in your neighborhood to shop for something other than cigarettes, how often do you decide to buy cigarettes? Possible response options were: 1 = never, 2 = rarely, 3 = sometimes, 4 = often, 5 = always. Aim 3. To employ a scale of POS tobacco marketing and examine its prospective association with quit attempt and quit success. Measurement of quit attempt and quit success: Both quit attempt and quit success were assessed at 6-month followup. Have you made any attempts to quit smoking since we last spoke with you in [month of last interview]? Yes/No Those who had made a quit attempt, were asked Are you back smoking or are you still stopped? If they indicated they were still stopped, we regarded them as having successfully quit smoking. Aim 4. to examine the relationship between POS cigarette marketing and SID and investigate how this relationship is mediated by cravings to smoke, urges to buy cigarettes, and unplanned purchases of cigarettes. Measurement of smoking-induced deprivation: In the past six months, has there been a time when the money you spent on cigarettes resulted in not having enough money for household essentials such as food? Yes/No 6

7 Findings 19 Findings All analyses controlled for nicotine dependence, sex, age, race/ethnicity, income, education, frequency of visits to stores, and method of recruitment. Aim 1. POS marketing and craving to smoke (Linear regression) Higher POS marketing associated with higher craving to smoke (P<0.001). Males, older age, higher income, higher education reported lower craving. Findings Aim 2. POS marketing, urge to buy cigarettes, and unplanned purchase of cigarettes (Linear regression) Higher POS marketing associated with urge to buy cigarettes (P<0.001) and higher frequency of unplanned purchases of cigarettes (P<0.013) Higher age and higher income associated with lower urge to buy. Higher education associated with lower unplanned purchases of cigarettes. Aim 3. POS marketing, quit attempt and quit success (logistic regression) Higher POS marketing not associated with quit attempt, but associated with a lower probability of quit success (p=0.006). Motivation to quit, having an intention to quit, and non-white race/ethnicity were associated with a higher probability of quit attempt. 7

8 Findings Aim 4. The relationship between POS cigarette marketing and SID; how this relationship is mediated by cravings to smoke, urges to buy cigarettes, and unplanned purchases of cigarettes. Note: Rectangles represent observed variables and ovals represent latent variables. All numbers outside parentheses are standardized coefficients. Numbers corresponding to error terms are error variances. Numbers in parentheses are p values. Summary of Results 1. POS tobacco marketing is associated with craving to smoke. 2. POS tobacco marketing is associated with an urge to buy cigarettes, and an unplanned purchase of cigarettes. 3. POS tobacco marketing is associated with quit success but not with quit attempt. 4. POS tobacco marketing is associated with SID. Conclusion and Discussion The study is important especially in view of the 2009 Family Smoking Prevention and Tobacco Control Act, which provide the FDA the authority to regulate tobacco marketing and allows states and local jurisdictions to enact tobacco marketing restrictions without being preempted by the federal government. We have shown that POS marketing indeed can act as a barrier to smoking cessation. These findings can provide part of the evidence-base needed by the FDA or local authorities to follow the lead of countries such as Australia, Canada, Norway, and Ireland and ban all forms of tobacco marketing. 8

9 Conclusion and Discussion There is a large evidence base about the effectiveness of population-level tobacco control policies in increasing smoking cessation rates. Policies such as increasing the price of tobacco products, restricting smoking in public places, and antismoking mass media campaigns have been shown by numerous studies to promote smoking cessation. The current study adds to this body of knowledge by suggesting that policies that reduce the amount of POS cigarette marketing might result in higher smoking cessation rates. Conclusion and Discussion SID and financial deprivation that result from smoking are important not only because they indicate compromised standards of living, but also because they can lead to further unfavorable smoking behaviors and outcomes. Smokers who experience SID are less likely to attempt to quit smoking and those who do try to quit are more likely to relapse. Similarly, smokers who experience financial stress are less likely to quit and ex-smokers who experience financial stress are more likely to relapse. Conclusion and Discussion The relationship between financial deprivation and smoking is reciprocal and smokers are often caught in a vicious cycle of experiencing financial deprivation because of smoking and not being able to quit because of the stress associated with financial deprivation. Our finding that POS cigarette marketing is associated with SID indicates that POS cigarette marketing can further exacerbate this vicious cycle. 9

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